In anticipation of major health care reform, it is essential that serious thought be given to its potential impact on the education of orthopedic residents and fellows.
An area of concern is the structure of orthopedic resident and fellow training. Our intention is not to propose specific solutions to every problem presented, but rather to give an opinion of modern training in hopes of bringing these issues to the table, and letting the educational powers that be debate and discuss possible solutions.
We are concerned with the structure of orthopedic residency programs that separate subspecialties to an exaggerated degree. We suspect that dividing a 5-year training period into too many separate blocks of time for each subspecialty makes some rotations shorter and probably insufficient.
Although creating a secure niche for the orthopedist via fellowships was true years ago when the number of residents seeking post-residency fellowships was small, an increasing number of fellowship-trained orthopedists are finding that being a focused subspecialist is no longer as realistic as it was before. This is particularly true in communities where a saturation of subspecialists in some areas denies them the opportunity to limit their practice to the topic of their fellowships. When choosing smaller communities, the problem becomes exponentially greater if subspecialists in their subdiscipline are already in practice because not enough patients are likely to be available to satisfy their professional and economic needs.
Has the proliferation of fellowships led to a decrease in resident education, or has the ever-changing field of orthopedics, with insufficient time of broad residency training, led to the proliferation of fellowships? Whichever came first, the chicken or the egg, we should study the most desirable way to define the role and placement of fellowships such that it does not interfere with the education of the resident.
The perception among many academicians is that the presence of fellows in residency programs has a beneficial effect on the education of the resident. We believe this perception is insufficiently supported with evidence, and in many institutions it is a deterrent to good resident education. Spine surgery is a well-known example where, in some institutions, orthopedic residents never serve beyond the level of second assistants in surgery throughout their entire training period, while fellows assume that responsibility. This has major implications to the overall role of orthopedics in spinal disorders. In contrast, neurosurgery training emphasizes resident involvement in surgery of the spine from the outset. Should this disparity in training experience continue, spine surgery will be completely dominated by neurosurgeons. The same will hold true with hand and foot/ankle subspecialties, which are becoming increasingly dominated by plastic surgeons and podiatrists, respectively. Whether this trend, which has comparable examples in other fields of medicine, is a healthy one is not yet known.
We must be certain that on completion of their training, residents possess the necessary clinical and surgical skills for the provision of adequate patient care in all areas of the discipline. The absence of such assurance is unacceptable. Because the education of the surgeon does not end with termination of residency, but continues throughout the life of the practitioner opportunities, to limit surgical work to one or a few areas of the profession will present and can be fully justified.
Eric D. Schiffman
We are not suggesting turning back the clock and recommending an overall rebirth of the general orthopedist. This would be a foolish and unrealistic project. There have been and always will be subspecialists in every branch of medicine and in many other segments of society. However, the trend suggesting that every orthopedist must be a subspecialist is equally unrealistic.
We suggest a reversal of certain traditional practices. Because fellows are in a specific institution for an entire year in a particular subspecialty, they should be the ones to serve primarily as second assistants in surgery while allowing the residents to be the first assistants. This suggestion, as illogical as it may appear to many, should not be dismissed too cavalierly. The fellows we are considering under this scenario will be individuals who, according to our suggested plan, would have received during their residency sufficient exposure to their subsequently chosen subspecialty. Their desire to improve the scope of their interests will not be compromised. In institutions with a great volume of surgical material, there will be ample opportunity for fellows and residents to serve as first assistants or as primary surgeons.
A number of fellowship training programs are not part of academic institutions and have no residents or medical students in their structure. They come under the aegis of community surgeons with large volumes of patients and surgeries. Many of these programs, although not involved in resident education, are good and provide education and experience to their fellows. These programs could be the best places for those who are eager to gain additional surgical experience without conflicting with resident education. Those who still wish to be in an academic setting should be willing to accept that residents are the priority. The responsibility of residency programs is the education of residents, not of fellows. If both can be accommodated without affecting resident education, so be it; otherwise, our appointed representative organizations should make the appropriate changes.
To further plan on changes in the structure of the educational process, the possibility of combining several distinct rotations could be considered, as well as eliminating some. For example, the rotations through orthopedic oncology, repeated twice over the 5 years, could be discontinued. However, to give residents adequate exposure to this important area, yearly seminars where comprehensive overviews are presented would be most appropriate. Grand rounds dealing with orthopedic oncology would also be held several times during the course of the 5 years. In addition, residents rotating through reconstructive surgery would be assigned to also participate, but to a lesser degree, in the surgical activities of the oncology section. Fellows who legitimately belong in oncology divisions would be the ones to actively participate in all surgical, clinical, and research activities.
We did not discuss the need to reduce the exaggerated role that industry plays in the education of residents and fellows, as depicted by their subsidy of fellowships and expenditures incurred attending alleged continuing education courses, which very often are primarily marketing ventures. The funding of guest speakers and visiting professors at grand rounds is similar, when these individuals are simply selling products produced by their sponsoring industrial firms. Our education should not be under the control of anyone outside of the profession, much less by industry, whose raison detre is the continued and uninterrupted increase in revenue and profitability. Industrys inappropriate excessive control of education is responsible not only for the ever-growing cost of care, but also for the gradual transformation of the traditional surgeon-scientist orthopedists into cosmetic surgeons of the skeleton by the abuse of technological advances and a parallel neglect of the fundamental biological and physiological foundation of our profession.
We trust the ideas we have expressed will be addressed by the appropriate powers that be to further prepare ourselves for what appears to be an inevitable health care reform.
Drs Sarmiento and Schiffman are from the Department of Orthopedics, University of Miami, Florida.
Drs Sarmiento and Schiffman have no relevant financial relationships to disclose.